New York State Water Infrastructure Improvement & Intermunicipal Water Infrastructure Grant Programs
Signature & Certification Form
On behalf of the Applicant, and in accordance with the Authorizing Resolution by the governing body of the Applicant authorizing me to do so, I apply for a WIIA grant and/or IMG grant for the project described in this application. By signing this application, I certify and agree on behalf of the Applicant and its governing body that all of the information contained in this application, in other statements and exhibits attached hereto or referenced herein, and in all statements, data and supporting documents which have been made or furnished for the purpose of receiving a WIIA grant or IMG grant for the project(s) described herein, are true, correct and complete to the best of my knowledge and belief.
I further agree on behalf of the Applicant that:
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If CWSRF assistance is provided for the project described in this application, the Applicant shall comply with all applicable provisions of the Federal Water Pollution Control Act, 33 U.S.C. §§ 1251 et. seq. Chapter 565 of the Laws of New York of 1989, 6 NYCRR Part 649 and 21 NYCRR Part 2602, as amended, regarding CWSRF assistance.
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If DWSRF assistance is provided for the project described in this application, the Applicant shall comply with all applicable provisions of the federal Safe Drinking Water Act, 42 U.S.C. §§ 300f, et seq., and applicable provisions of state law, codified under Chapter 413 of the Laws of New York of 1996, 10 NYCRR Part 53, and 21 NYCRR Part 2604, as amended, regarding DWSRF assistance.
I further agree that the Applicant will comply with the provisions of the Minority and Women’s Business Enterprise – Equal Employment Opportunity requirements of Article 15-A of the New York State Executive Law, and will maintain such records and take such actions necessary to demonstrate such compliance throughout the construction of the project.
Further, I acknowledge that offering a written instrument knowing that the written instrument contains a false statement or false information, with the intent to defraud the State or any political subdivision, public authority or public benefit corporation of the State, with the knowledge or belief that it will be filed with or recorded by the State or any political subdivision, public authority or public benefit corporation of the State, constitutes a crime under New York State Law.
SIGN
(Signature of Authorized Municipal Representative)
(Date)
Karen Sm Karen Smytheythe- Ma Mayor yor (Authorized Representative Name and Title)
Villa Village ge of Red Hook of Red Hook
(Municipal Applicant)
WIIA / IMG Grant Signature & Certification Form
6/2025